MEDICARE: BULLDOG PHARMACY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0004X	Compounding Pharmacy
2	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1700458213
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BULLDOG PHARMACY, LLC

Provider Business Mailing Address
First Line	:	PO BOX 187
Second Line	:
City	:	GRAND SALINE
State	:	TX
Zip	:	75140-0187
Country	:	US
Telephone Number	:	903-385-1122
Fax Number	:	903-385-1124

Provider Business Practice Location Address
First Line	:	115 N HOUSTON ST
Second Line	:
City	:	EDGEWOOD
State	:	TX
Zip	:	75117-2502
Country	:	US
Telephone Number	:	903-385-1122
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PIC
Name	:	DR. HOLLY RENEE RANDOLPH
Credential	:	PHARMD, RPH
Telephone Number	:	903-385-1122

Provider Enumeration Date	:	07/14/2021
Last Update Date	:	12/23/2021

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